Upper rectus abdominis paralysis after robot-assisted thoracic oncology surgery with cryoanalgesia: A rare complication

Abstract

Central MessagePermanent rectus paralysis after lung surgery is rare but with potentially esthetic repercussions. Patients could benefit from early recognition of lesions responsible for postoperative discomfort.See Commentaries on pages 538 and 540. Permanent rectus paralysis after lung surgery is rare but with potentially esthetic repercussions. Patients could benefit from early recognition of lesions responsible for postoperative discomfort. See Commentaries on pages 538 and 540. Intercostal nerve damage resulting in motor dysfunction is more infrequent compared with sensory loss after thoracic surgery. Considering intercostal nerves as mixed-type nerves, chronic pain incidence is up to 50%,1Kehlet H. Jensen T.S. Woolf C.J. Persistent postsurgical pain: risk factors and prevention.Lancet. 2006; 367: 1618-1625Abstract Full Text Full Text PDF PubMed Scopus (2542) Google Scholar and there is a strong discrepancy in the presence of paralysis. Only a few case reports of paralysis after video-assisted thoracic surgery (VATS) have been published. We report the first case of rectus abdominis atrophy after robot-assisted VATS (RA-VATS). A 55-year-old man underwent RA-VATS lobectomy due to malignancy (17 mm carcinoid tumor, pT1 N0 G1 R0 [based on TNM eighth edition]). Preoperative clinical examination showed no abnormalities. To expedite enhanced recovery after surgery, as per institutional protocol, cryoanalgesia (Metrum Cryoflex; Cryo-S, Warsaw, Poland) was performed intraoperatively. The team has acquired solid expertise in the use of cryotherapy for pain treatment (>500 procedures) and has been using this technique during surgery without any complication. Few potential side effects are reported, including local bleeding and bruising; no motor dysfunction has been described. Unsurprisingly, local hypoesthesia may develop. Surgical installation and 4-port placement are illustrated in Figure 1. The cryoprobe was inserted through the preexisting entry ports and applied under direct visualization at intercostal nerves 6, 7, and 8. Cryoablation was performed lege artis for 90 seconds at a temperature of −80°C followed by a defreezing period resulting in a nerve lesion of Seddon and Sunderland classification axonotmesis grade II, which spontaneously resolved after 4 months.2Ilfeld B.M. Preciado J. Trescot A.M. Novel cryoneurolysis device for the treatment of sensory and motor peripheral nerves.Expert Rev Med Device. 2016; 13: 713-725Crossref PubMed Scopus (48) Google Scholar One of the author (S.K.Y.) have made a video tutorial on robot-assisted lung surgery for The Multimedia Manual of Cardio-Thoracic Surgery on behalf of the European Association for Cardio-Thoracic Surgery, available at https://mmcts.org/tutorial/1481. RA-VATS has increased in popularity during the past 2 decades because it offers 3-dimensional optics, increased instrument and wrist flexibility compared with classical VATS, and for patients it offers improved quality of life and shorter hospital stays compared with open surgery. In this video tutorial, we demonstrate a RA-VATS lobectomy in a patient with a tumor in the right middle lobe. The patient presented in the case report had identical tumor characteristics and mass localization. A localized painful area below the levels of the cryoanalgesic procedure with numeric rating score of 3 was declared during coughing. No hyperalgesia or allodynia was reported besides the expected hypoesthesia at dermatomes Th6, Th7, and Th8. The patient returned 4 months later with painless right-sided abdominal swelling (Figure 2, A) that he noticed several weeks after surgery. A computed tomography scan ruled out underlying pathology. In addition to the suggestive clinical examination, electromyography evaluation confirmed permanent denervation of the upper two-thirds of the rectus and external oblique abdominal wall muscles. Retrospective image review confirmed rectus abdominis atrophy with lipomatous involution confirming concomita